Ep 144 Testicular Torsion: A Diagnostic Pathway

In this Part 2 of Urologic Emergencies EM Cases main episode podcasts Dr. Natalie Wolpert and Dr. Yonah Krakowsky answer questions about testicular torsion including: when, after the onset of symptoms, is the testicle salvageable? How sensitive is the presence of cremasteric reflex in ruling out testicular torsion? Are there any set of clinical symptoms and signs or decision tools (such as the TWIST Score) that can rule in or rule out testicular torsion with confidence? How accurate is doppler ultrasound in the diagnosis of testicular torsion? To what degree does Prehn's sign help distinguish epididymitis from testicular torsion? How can you distinguish testicular torsion from torsion of testicular appendage? When is manual de-torsion indicated and how effective is it? and many more... Podcast voice editing by Emma Helman; production, sound design & editing by Anton Helman Written Summary and blog post by Winny Li, edited by Anton Helman July, 2020. Cite this podcast as: Helman, A. Krakowsky, Y. Wolpert, N. Testicular Torsion: A Diagnostic Pathway. Emergency Medicine Cases. July, 2020. https://emergencymedicinecases.com/testicular-torsion. Accessed [date] Go to part 1 of this 2-part podcast on urologic emergencies Testicular torsion occurs when the spermatic cord twists leading to impaired blood flow to the testicle, causing ischemia and potentially tissue necrosis. A bell clapper deformity is a predisposing factor in testicular torsion where the tunica vaginalis attaches high on the spermatic cord, leaving the testis free to rotate within the tunica vaginalis. Time is Testes Historically, we thought the time window for possible salvage and survival of a torsed testicle is 6-8 hours. However, more recently it has been recognized that survival percentages are significant beyond the commonly held 6 to 8-hour time frame and even after 24 hours. During this time, there may be intermittent torsion detorsion, leading to the variable spectrum of salvageability and difficulty in predicting the precise onset of irreversible ischemia. Bottom line: Duration of symptoms should not guide management decisions. All cases of suspected testicular torsion must be treated as a surgical emergency, even if the time from onset is beyond 6-8 hours. The sooner the testicle is de-torsed, the more likely salvageability. Testicular torsion can occur at any age Testicular torsion can occur at any age, but it is primarily associated with a bimodal distribution in the first year of life and in adolescence. Although exceedingly rare, there are case reports of testicular torsion occurring in men over the age of 40. We should therefore still maintain an index of suspicion for testicular torsion in older men who present with unilateral acute scrotal pain. Classic Signs and Symptoms of Testicular Torsion * Acute unilateral pain * Scrotal erythema, edema and swelling * Absent cremasteric reflex * Position: high, horizontal lie * Nausea and vomiting Acute unilateral pain Most patients with testicular torsion will present with sudden onset of severe unilateral testicular pain, often radiating to the groin/abdomen/flank. However, there are subsets of patients who will present with gradual onset of pain, minimal or no pain, intermittent pain caused by intermittent torsion/detorsion or resolution of their initial severe pain followed by reduced pain. Up to 20% of patients with testicular torsion will present with isolated lower abdominal pain. All male patients presenting with lower abdominal pain should have a gentile examination for signs of torsion. Swelling